本文關(guān)鍵詞：臟腑辨證指導(dǎo)下絕經(jīng)后婦女KOA經(jīng)筋病變的治療及經(jīng)筋通方干預(yù)機(jī)制研究　出處：《廣州中醫(yī)藥大學(xué)》2017年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 絕經(jīng)后婦女 膝骨關(guān)節(jié)炎 經(jīng)筋辨證 臟腑辨證 經(jīng)筋通方

【摘要】：目的:分析膝骨關(guān)節(jié)炎(Knee Osteoarthritis,KOA)經(jīng)筋分型與中醫(yī)證型、證素對應(yīng)關(guān)系,觀察在臟腑辨證指導(dǎo)下采用經(jīng)筋通方治療絕經(jīng)后婦女KOA經(jīng)筋病變的臨床療效,進(jìn)而采用去勢大鼠KOA模型模擬絕經(jīng)后婦女膝關(guān)節(jié)軟骨退變微環(huán)境,探討經(jīng)筋通方治療去勢大鼠KOA筋骨病變的分子機(jī)制。以明確在臟腑辨證指導(dǎo)下采用經(jīng)筋通方治療絕經(jīng)后婦女KOA經(jīng)筋病變體現(xiàn)治病求本、筋骨并重中醫(yī)學(xué)術(shù)思想。方法:選取廣州中醫(yī)藥大學(xué)第三附屬醫(yī)院門診絕經(jīng)后KOA患者,制定選擇標(biāo)準(zhǔn),將符合標(biāo)準(zhǔn)的患者納入研究,采用臟腑辨證獲取中醫(yī)證型、證素,經(jīng)筋辨證獲取經(jīng)筋分型,將所獲得資料建立數(shù)據(jù)庫,觀察經(jīng)筋分型在中醫(yī)證型、證素中分布情況,采用SPSS18.0軟件進(jìn)行對應(yīng)分析研究。將選取的研究對象分為觀察組和對照組,觀察組口服經(jīng)筋通方,每天1次,每周6次,2周為1個療程,連續(xù)服用3個療程,對照組采用經(jīng)絡(luò)電針療法治療,每2天1次,每周3次,2周為1療程,連續(xù)治療3個療程。治療結(jié)束后采用WOMAC、JOA、Lysholm評分評價膝關(guān)節(jié)功能,采用VAS評分評價疼痛緩解程度,記錄治療期間并發(fā)癥發(fā)生情況,觀察兩組療效之間的差異。運(yùn)用SPSS18.0軟件對數(shù)據(jù)進(jìn)行統(tǒng)計處理,首先進(jìn)行方差齊性檢驗(yàn),若方差齊選用獨(dú)立樣本t檢驗(yàn),若方差不齊選用Kruskal-Wallis非參數(shù)方差分析,并發(fā)癥的比較采用χ2檢驗(yàn),療效比較采用Wilcoxon秩和檢驗(yàn)。18只6月齡雌性SD大鼠采用隨機(jī)數(shù)字表法隨機(jī)分為OVX+KOA組、OVX組和Sham組,每組6只。OVX+KOA組大鼠去勢2周后建立KOA模型,OVX組大鼠去勢后僅行膝關(guān)節(jié)脫位處理,Sham組摘除卵巢旁邊的脂肪組織和膝關(guān)節(jié)脫位處理,所有大鼠造模1周后在動物實(shí)驗(yàn)跑臺跑道中奔跑2周,1.5個月后采用ELISA檢測血清E2、COMP含量,采用HE染色觀察膝關(guān)節(jié)軟骨和腓腸肌形態(tài)學(xué)變化。數(shù)據(jù)的統(tǒng)計與處理采用SPSS18.0軟件,首先進(jìn)行方差齊性檢驗(yàn),若方差齊選用單因素方差分析LSD法,若方差不齊選用Kruskal-Wallis非參數(shù)方差分析。72只6月齡雌性SD大鼠采用隨機(jī)數(shù)字表法隨機(jī)分為假手術(shù)組、模型組、經(jīng)筋通高劑量組、經(jīng)筋通中劑量組、經(jīng)筋通低劑量組和陽性對照組,每組12只。OVX+KOA模型建立1周后在動物實(shí)驗(yàn)跑臺奔跑,同時給予藥物干預(yù)。經(jīng)筋通高、中、低劑量組給予經(jīng)筋通方,陽性對照組給予塞來昔布膠囊。經(jīng)筋通高劑量組給藥劑量為3.80g/100g/d,經(jīng)筋通中劑量組給藥劑量為1.90g/100g/d,經(jīng)筋通低劑量組給藥劑量為0.95g/100g/d,陽性對照組給藥劑量為2.06mg/100g/d,假手術(shù)組和模型組給予同體積的生理鹽水。每天給藥1次,每周給藥6天,休息1天。每周稱1次體重,根據(jù)體重調(diào)整給藥劑量,給藥時間持續(xù)1.5個月。給藥結(jié)束后采用ELISA檢測血清E2、COMP含量,RT-PCR檢測膝關(guān)節(jié)軟骨ERRa、PGC-1a、Sox9、IL-1βmRNA表達(dá),免疫組化檢測腓腸�、蛐湍z原表達(dá)。數(shù)據(jù)的統(tǒng)計與處理采用SPSS18.0軟件,首先進(jìn)行方差齊性檢驗(yàn),若方差齊選用單因素方差分析LSD法,若方差不齊選用Kruskal-Wallis非參數(shù)方差分析。結(jié)果:共有84例絕經(jīng)后KOA患者符合選擇標(biāo)準(zhǔn)納入研究,其中經(jīng)筋病變以足陽明經(jīng)筋為主,其次為足太陽經(jīng)筋、足三陰經(jīng)筋和足少陽經(jīng)筋,所占比例分別為39%、23%、20%及18%;中醫(yī)證型以瘀血閉阻為主,其次為肝腎虧虛、風(fēng)寒濕痹和風(fēng)濕熱痹,所占比例為44.45%、30.95%、26.19%及17.86%;中醫(yī)證型與經(jīng)筋分型對應(yīng)分析顯示,兩者間存在屬性關(guān)聯(lián)且有統(tǒng)計學(xué)意義(χ2=38.814,P=0.000)。以中醫(yī)證型與經(jīng)筋分型點(diǎn)與點(diǎn)的距離觀察,足陽明經(jīng)筋病變和足少陽經(jīng)筋病變與風(fēng)寒濕痹、風(fēng)濕熱痹關(guān)系密切,足三陰經(jīng)筋病變與瘀血閉阻關(guān)系密切,足太陽經(jīng)筋病變與肝腎虧虛關(guān)系密切。中醫(yī)證素中足陽明經(jīng)筋病變以濕邪、瘀血及脾虛為主,足太陽經(jīng)筋病變以腎虛、肝虛為主,足少陽經(jīng)筋病變以瘀血、濕邪為主,足三陰經(jīng)筋病變以瘀血、肝虛為主;中醫(yī)證素與經(jīng)筋分型對應(yīng)分析顯示,兩者間不存在屬性關(guān)聯(lián)且無統(tǒng)計學(xué)意義(χ2=24.688,P=0.423)。將上述84例絕經(jīng)后KOA患者納入本次研究,12例不滿足選擇標(biāo)準(zhǔn)予以剔除,剩余72例符合選擇標(biāo)準(zhǔn)納入研究,其中觀察組38例,對照組34例。兩組患者年齡、體重、身高、BMI、絕經(jīng)年限、病程、側(cè)別和Kellgren-Lawrence分級比較,差異無統(tǒng)計學(xué)意義(P0.05),具有可比性。治療后,兩組患者WOMAC評分中疼痛、僵硬、活動難度和總評分顯著降低,與治療前比較差異具有統(tǒng)計學(xué)意義(P0.05),但兩組間比較,差異無統(tǒng)計學(xué)意義(P0.05),兩組差值比較,差異無統(tǒng)計學(xué)意義(P0.05);兩組患者JOA、Lysholm評分顯著增高,與治療前比較差異具有統(tǒng)計學(xué)意義(P0.05),但兩組間比較,差異無統(tǒng)計學(xué)意義(P0.05),兩組差值比較,差異無統(tǒng)計學(xué)意義(P0.05);兩組患者VAS評分顯著降低,與治療前比較差異具有統(tǒng)計學(xué)意義(P0.05),但兩組間比較,差異無統(tǒng)計學(xué)意義(P0.05),兩組差值比較,差異無統(tǒng)計學(xué)意義(P0.05);觀察組總有效率為89.47%,對照組總有效率為88.24%,兩組間經(jīng)Wilcoxon秩和檢驗(yàn),差異無統(tǒng)計學(xué)意義(Z=-0.367,P=0.714)。治療期間,兩組患者未訴明顯不適,未發(fā)現(xiàn)惡心、嘔吐等消化系統(tǒng)癥狀,未發(fā)現(xiàn)心痛、心悸等心血管系統(tǒng)癥狀,未出現(xiàn)暈針、針柄斷裂、過敏反應(yīng)等并發(fā)癥,未出現(xiàn)其他經(jīng)筋及復(fù)合經(jīng)筋病變。造模后1.5個月,大鼠處死前三組體重比較經(jīng)方差齊性檢驗(yàn)P=0.5270.05,說明具有方差齊性,采用單因素方差分析LSD法,經(jīng)分析差異無統(tǒng)計學(xué)意義(P0.05),具有可比性。OVX+KOA組和OVX組血清E2含量明顯低于Sham組(P0.05),OVX+KOA組與OVX組比較,組間差異無統(tǒng)計學(xué)意義(P0.05);OVX組血清COMP含量高于Sham組,但兩組間比較差異無統(tǒng)計學(xué)意義(P0.05),OVX+KOA組血清COMP含量高于OVX組和Sham組,與OVX組比較,差異無統(tǒng)計學(xué)意義(P0.05),與Sham組比較,差異具有統(tǒng)計學(xué)意義(P0.05)。HE染色見OVX+KOA組軟骨表面粗糙不平,皸裂或鋸齒狀改變,軟骨表層纖維化,軟骨細(xì)胞數(shù)量減少,細(xì)胞核呈藍(lán)色,細(xì)胞外基質(zhì)呈紅色,軟骨陷窩空虛,潮線上移、中斷或多重潮線;三組腓腸肌可見細(xì)胞核呈藍(lán)色,分布于肌纖維之間,肌纖維呈多角形,OVX+KOA組肌纖維粘連,排列紊亂,OVX組和Sham組肌纖維排列整齊,與Sham組比較,OVX+KOA組和OVX組肌細(xì)胞核數(shù)量減少,OVX組肌纖維間距增寬。藥物干預(yù)1.5個月后,多組間各個指標(biāo)比較經(jīng)方差齊性檢驗(yàn)P0.005,不符合方差齊性,采用Kruskal-Wallis非參數(shù)方差分析。模型組與假手術(shù)組比較,血清E2、COMP含量差異具有統(tǒng)計學(xué)意義(P0.05);經(jīng)筋通高、中劑量組及陽性對照組與模型組比較,血清E2、COMP含量差異具有統(tǒng)計學(xué)意義(P0.05);經(jīng)筋通高、中劑量組與陽性對照組比較,血清E2含量差異具有統(tǒng)計學(xué)意義(P0.05)。與假手術(shù)組比較,模型組ERRα、SOX9mRNA表達(dá)量明顯降低(P0.05),PGC-1α、IL-1βmRNA表達(dá)量明顯增高(P0.05)。采用經(jīng)筋通方干預(yù)后,與模型組比較,經(jīng)筋通高劑量組ERR α、SOX9 mRNA表達(dá)量明顯升高(P0.05),PGC-1α、IL-1βmRNA表達(dá)量明顯降低(P0.05),經(jīng)筋通中劑量組ERRα mRNA表達(dá)量明顯升高(P0.05),PGC-1 α、IL-1 β mRNA表達(dá)量明顯降低(P0.05),經(jīng)筋通低劑量組PGC-1α、IL-1βmRNA表達(dá)量明顯降低(P0.05)。與陽性對照組比較,經(jīng)筋通高劑量組ERRα、SOX9 mRNA表達(dá)量明顯升高(P0.05),經(jīng)筋通中劑量組PGC-1α、IL-1βmRNA表達(dá)量明顯升高(P0.05),經(jīng)筋通低劑量組ERR α、SOX9 mRNA表達(dá)量明顯降低(P0.05),PGC-1α、IL-1 β mRNA表達(dá)量明顯升高(P0.05)。與假手術(shù)組比較,模型組Co12αl蛋白陽性評分明顯降低(P0.05)。與模型組比較,經(jīng)筋通高、中劑量組和陽性對照組Col2α1蛋白陽性評分明顯升高(P0.05)。與陽性對照組比較,經(jīng)筋通高、中劑量組Col2α1蛋白陽性評分明顯升高(P0.05),經(jīng)筋通低劑量組明顯降低(P0.05)。結(jié)論:KOA經(jīng)筋分型和中醫(yī)證型存在對應(yīng)關(guān)系,在臟腑辨證指導(dǎo)下采用經(jīng)筋通方治療絕經(jīng)后婦女KOA經(jīng)筋病變能夠取得良好臨床療效。去勢大鼠KOA模型存在膝關(guān)節(jié)軟骨和腓腸肌病變,能夠較好地模擬絕經(jīng)后婦女膝關(guān)節(jié)退變微環(huán)境。經(jīng)筋通方能夠調(diào)節(jié)去勢大鼠KOA膝關(guān)節(jié)軟骨IL-1 β/ERR α/PGC-1 α/SOX9信號通路表達(dá),提高腓腸�、蛐湍z原蛋白表達(dá),從而發(fā)揮治療KOA筋骨病變的作用。綜合分析可知,在臟腑辨證指導(dǎo)下采用經(jīng)筋通方治療絕經(jīng)后婦女KOA經(jīng)筋病變可能是通過調(diào)節(jié)膝關(guān)節(jié)軟骨IL-1 β/ERRα/PGC-1 α/SOX9信號通路表達(dá),提高腓腸�、蛐湍z原蛋白表達(dá)而發(fā)揮治療作用,體現(xiàn)治病求本、筋骨并重學(xué)術(shù)思想。
[Abstract]:Objective: to analyze the knee osteoarthritis (Knee Osteoarthritis, KOA) tendons and TCM syndromes, syndrome element relationship, observe the in viscera syndrome differentiation under the guidance of Jingjin Decoction in treating postmenopausal women KOA clinical efficacy of tendon lesions, then the ovariectomized rats KOA model of postmenopausal women with knee joint cartilage the degeneration of micro environment, and to explore the molecular mechanism of Jingjin Decoction in treating ovariectomized rats and KOA lesions. In order to make clear in the viscera and under the guidance of the Jin Tong Decoction in the treatment of postmenopausal women with KOA tendon lesion for the treatment of bones, Chinese academic thought. Methods: a total of Third Affiliated Hospital of Guangzhou University of Chinese Medicine of postmenopausal KOA patients. Set the selection criteria, will meet the criteria were included in the study, the acquisition of viscera syndrome differentiation of TCM, syndrome, meridian sinew differentiation obtained by reinforcement type, the obtained data database, observe the bar type In TCM, syndrome distribution were studied. Corresponding analysis using SPSS18.0 software to study were divided into observation group and control group, observation group received by Jin Tong, 1 times a day, 6 times a week, 2 weeks for 1 courses, for taking 3 courses, the control group. With the meridian electro acupuncture therapy treatment, 1 times every 2 days, 3 times a week, 2 weeks as 1 course of treatment, continuous treatment of 3 courses. After treatment with WOMAC, JOA, Lysholm score of knee joint function was evaluated with VAS degree of pain relief and complications were recorded during treatment, observe the differences between the two groups. Using SPSS18.0 software for statistical data processing, firstly, homogeneity of variance test, if the variance using independent sample t test, if the variance is not homogeneous with Kruskal-Wallis non parametric analysis of variance, were compared using 2 test, the curative effect was compared with Wilcoxon and rank Test.18 June old female SD rats were randomly divided into OVX+KOA group, OVX group and Sham group, each group of 6 rats in the.OVX+KOA group were ovariectomized for 2 weeks to establish KOA model, OVX group of castrated rats were only knee dislocation treatment, Sham group ovariectomy beside the adipose tissue and knee joint dislocation treatment, all rats after 1 weeks in the experimental animal treadmill running in the runway for 2 weeks, 1.5 months after the detection of serum E2, ELISA content of COMP, HE staining was used to observe the articular cartilage of the knee and calf muscle morphological changes. Statistics and data processing using SPSS18.0 software, the first test of homogeneity of variance if the variance, using single factor analysis of variance LSD method, if the homogeneity of variance using Kruskal-Wallis non parametric analysis of variance.72 June old female SD rats were randomly divided into sham operation group, model group, high dose group of tendons, tendon through middle dose The Jin Tong Group, low dose group and positive control group, 12 rats in each group 1 weeks after the establishment of.OVX+KOA model in animal experiments of treadmill running, given the drug intervention at the same time. The band pass high, low dose group was treated with Jin Tong, the positive control group was given by Celecoxib Capsules. The high dose group was administered through the bars the amount is 3.80g/100g/d, the reinforcement through the middle dose group was administered at a dose of 1.90g/100g/d tendons through low dose group the dosage was 0.95g/100g/d, the positive control group the dosage was 2.06mg/100g/d, sham operation group and model group were given the same volume of saline. Administered 1 times daily, weekly administration of 6 days, the rest of the 1 day. Weekly said 1 times according to the weight, weight adjusted dosage, dosing time lasts for 1.5 months. After the end of dosing by detection of serum E2 and ELISA content of COMP, RT-PCR detection of articular cartilage ERRa, PGC-1a, Sox9, the expression of IL-1 beta mRNA, immunohistochemical detection of gastrocnemius muscle of type II collagen sheet Da. Statistics and data processing by SPSS18.0 software, firstly, homogeneity of variance test, if the variance using single factor analysis of variance LSD method, if the homogeneity of variance using Kruskal-Wallis nonparametric variance analysis. Results: a total of 84 cases of postmenopausal KOA patients met the selection criteria included in the study, the tendon lesion with Foot Yangming the tendons, followed by meridian tendons, three yin meridians of the foot tendons and Zu Shaoyang tendons, the proportion was 39%, 23%, 20% and 18%; TCM syndrome type of blood stasis obstructing, followed by liver and kidney deficiency, cold and dampness and rheumatic fever, accounted for 44.45%, 30.95% 26.19%, and 17.86%; TCM syndrome type and the reinforcement type correspondence analysis showed that attribute correlation exist between them and there was statistical significance (2=38.814, P=0.000). The TCM syndrome type and the reinforcement type and the distance of observation, Foot Yangming Meridian of foot Shao Yang rib lesions and tendon lesion with cold dampness Arthritis, rheumatic fever is closely related to the three yin meridians of foot muscle lesions and blood stasis obstructing closely meridian tendon lesion with deficiency of liver and kidney are closely related. TCM syndrome factors of Foot Yangming Meridian tendon lesion to dampness, blood stasis and spleen deficiency, meridian tendons disease with kidney deficiency, liver deficiency, foot Shaoyang tendon lesion with blood stasis and dampness, three yin meridians of foot tendon lesion with blood stasis, liver deficiency; TCM syndrome elements and the reinforcement type correspondence analysis showed that between the two there is no association and not statistically significant (2=24.688, P=0.423). This study will be included in the 84 cases of postmenopausal KOA patients in 12 cases, does not meet the selection criteria to be removed, the remaining 72 cases meet the selection criteria in the study, 38 cases in the observation group, 34 cases in the control group. Two groups of age, weight, height, BMI, menopause, duration, comparison side and Kellgren-Lawrence classification, there was no statistically significant difference (P0.05), with Comparable. After treatment, the pain, the WOMAC score of the two groups in stiffness, difficulty and the total score decreased significantly, compared with before treatment, the difference was statistically significant (P0.05), but the comparison between the two groups, the difference was not statistically significant (P0.05), compare the difference between the two groups, the difference was not statistically significant (P0.05); two groups of patients JOA, Lysholm were significantly increased, compared with before treatment, the difference was statistically significant (P0.05), but the comparison between the two groups, the difference was not statistically significant (P0.05), compare the difference between the two groups, the difference was not statistically significant (P0.05); the two groups of patients VAS score decreased significantly, compared with before treatment with statistical difference meaning (P0.05), but the comparison between the two groups, the difference was not statistically significant (P0.05), compare the difference between the two groups, the difference was not statistically significant (P0.05); the total efficiency of the observation group was 89.47%, control group total effective rate was 88.24%, between the two groups by Wilcoxon rank sum test, no statistical difference Learn the meaning of (Z=-0.367, P=0.714). During the treatment, two patients were not told not found obvious discomfort, nausea, vomiting and other gastrointestinal symptoms, found no heartache, palpitations and other symptoms of cardiovascular system, without treatment, the needle handle fracture, allergic reactions and other complications, he did not appear the tendons and tendon lesion composite at 1.5 months after modeling, rats were sacrificed before the three groups by weight difference test of homogeneity of P=0.5270.05, indicating the homogeneity of variance, LSD analysis by single factor variance analysis, the difference was not statistically significant (P0.05), comparable to.OVX+KOA group and OVX group serum E2 content was significantly lower than in group Sham (P0.05), OVX+KOA group and OVX group, no significant difference between the groups (P0.05); OVX serum COMP was higher than Sham group, but there was no significant difference between the two groups (P0.05), OVX+KOA group of serum COMP content was higher than OVX group and Sham group compared with OVX group, no significant difference Statistically significant (P0.05), compared with Sham group, the difference was statistically significant (P0.05).HE staining group OVX+KOA cartilage surface is rough, chapped or jagged, cartilage surface cartilage fibrosis, decrease in the number of cells, nuclei were blue, extracellular matrix of cartilage lacuna was red, empty, tide line up, or interrupt multiple tidal line; three groups of gastrocnemius muscle cell nuclei were blue, distributed in the muscle fibers, muscle fibers were polygonal, group OVX+KOA muscle fiber adhesion, disorder, OVX group and Sham group of muscle fibers arranged neatly, compared with Sham group, OVX+KOA group and OVX group to reduce the number of muscle cells, OVX muscle fiber spacing increases wide. 1.5 months after drug intervention, the homogeneity test of P0.005 of each index by variance comparison among multiple groups, does not meet the homogeneity of variance, the variance analysis of non Kruskal-Wallis parameters. The model group and the sham group compared with serum E2, COMP content difference 緇熻瀛︽剰涔，

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